Family Wins Cochlear Implant Insurance Victory Growing up deaf, it took years for 16-year-old Mila O’Bryant to make a decision to get a cochlear implant, and she was ecstatic to be considered a candidate. But in an era when insurance reimbursement for cochlear implantation is routine, a stunning insurance denial threatened to silence her dreams. In ... Features
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Features  |   December 01, 2005
Family Wins Cochlear Implant Insurance Victory
Author Notes
  • Susan Boswell, an assistant managing editor of The ASHA Leader, can be reached at sboswell@asha.org.
    Susan Boswell, an assistant managing editor of The ASHA Leader, can be reached at sboswell@asha.org.×
Article Information
Hearing Aids, Cochlear Implants & Assistive Technology / Features
Features   |   December 01, 2005
Family Wins Cochlear Implant Insurance Victory
The ASHA Leader, December 2005, Vol. 10, 4-13. doi:10.1044/leader.FTR1.10172005.4
The ASHA Leader, December 2005, Vol. 10, 4-13. doi:10.1044/leader.FTR1.10172005.4
Growing up deaf, it took years for 16-year-old Mila O’Bryant to make a decision to get a cochlear implant, and she was ecstatic to be considered a candidate. But in an era when insurance reimbursement for cochlear implantation is routine, a stunning insurance denial threatened to silence her dreams.
In a routine call to her primary care physician, Mila O’Bryant’s mother Kathy O’Bryant requested a series of referrals required by their managed health care plan to complete the cochlear implant candidacy process beyond the initial consultation and audiological testing at Oregon Health & Science University (OHSU). But instead of a referral, Mila O’Bryant was denied a cochlear implant because she is prelingually deaf.
A letter from their insurance plan, PacifiCare of Oregon, stated that the physician panel who reviews referral requests found that, “Mila does not meet the criteria for clinical indication for surgery because she was not postlingually deafened.” O’Bryant would need to provide documentation that her daughter could speak before she became deaf.
It was impossible to prove. “When we adopted Mila from Bulgaria a decade ago, she was six years old and had no language at all-verbal or sign,” O’Bryant recalled. “We put hearing aids on her and she wore them for a short period of time, and then quit.”
Her daughter recalled the confusion of those early days. “I hated sound because I didn’t understand what sound meant. But then I noticed that people around me used sound, and I started to think about that,” she said. “I realize that I struggle because I can’t hear, and now I’m ready for the cochlear implant.”
A month later in July, O’Bryant was finally able to get in contact with her primary care physician and express her desire to obtain a cochlear implant for her daughter. The physician agreed to take the request back to the physician panel, which again quickly responded with a denial. O’Bryant was told to file an appeal.
“It never surprises me what an insurance company does,” said Don Plapinger, director of Clinical Audiology at OHSU. “In this case, I got a call from the insurance company asking for input-but before I could respond, she was denied. With this insurance company, the issue of denying for Mila but approving for younger children and postlingually deafened adults was a surprise.”
Overturning a Denial
When Mila O’Bryant’s guidance counselor asked about the cochlear implant several weeks later, her mother told her it had been denied. The counselor put her in touch with attorney Lew Golinker, of the Assistive Technology Law Center, in Ithaca, NY, who had earlier helped with an insurance appeal for her own son. Golinker outlined steps that would serve as the basis for an appeal:
  • Review insurance documents and contract for specific exclusions or inclusions related to cochlear implantation

  • Review information related to the safety and efficacy of cochlear implants by the U.S. Food and Drug Administration

  • Determine Medicare’s coverage of cochlear implantation and criteria for coverage

  • Identify insurance companies in Oregon that have covered cochlear implantation

  • In the process of gathering information, O’Bryant turned to ASHA for information and guidance in writing an appeals letter.

“Without ASHA’s assistance, my appeal would have been like a mom writing a letter,” O’Bryant said. “But the letter I sent was powerful. They could see that I’d done my research and found an advocate and that I was willing to fight.”
The letter noted that the requirement that one must first possess an ability and then lose it does not allow for the medically-related needs of children. Maryland corrected this by passing a law that requires insurers to cover “habilitative services for children.”
“When illness or injury prevents a young child from developing basic abilities (e.g., walking or talking), medically necessary services to treat the disorder should be covered. I cannot believe that PacifiCare intended to deny therapeutic medical services to children,” the letter stated.
The letter also noted that PacifiCare’s requirement that an individual must be postlingually deafened to receive a cochlear implant is inconsistent with Medicare’s coverage.
After the letter was sent, wheels began to turn. Two weeks later, the insurance company called and asked for the individuals that issued the denial, because there was no denial on record. Several weeks later, the correct referrals were finally issued and O’Bryant had a letter stating that the cochlear implant surgery would be reimbursed. “Without ASHA, I don’t know if we would have had the same outcome,” she said.
From Silence to Sound
The cochlear implant was her daughter’s idea, O’Bryant noted. “I never promoted the cochlear implant to Mila, and I wasn’t a big fan,” she said, citing concerns about the surgery, opposition among the Deaf community, and her daughter’s contentment with deafness.
The family, which includes an adopted older brother who also has hearing loss, had learned American Sign Language and immersed themselves in the local Deaf community.
But a family friend has a daughter who is now 11 years old and received a cochlear implant at 18 months. When she upgraded to an ear-level sound processor, Mila O’Bryant decided that she wanted a cochlear implant and didn’t stop talking about it.
O’Bryant suggested that if her daughter wanted a cochlear implant, she needed to wear her hearing aid and use speech and speechreading consistently. Mila O’Bryant, who has never heard speech before, began receiving speech services in school over the past year. “She’s done incredibly well and can now speak some two-syllable words,” Kathy noted.
With all implant candidates, Plapinger noted, counseling the family is the most important aspect of the evaluation process. “Mila’s situation is unique,” he said, adding that he expects her to benefit through her awareness of sounds in her environment.
Mila O’Bryant was able to explain what she expects from the implant. She also asked some questions that demonstrated the depth of her own research.
“I want to be able to learn all these sounds that everybody else is able to hear, like machines, dogs barking, and the vacuum cleaner. I want to be able to look at something and understand what it sounds like,” she said.
As O’Bryant looks forward to the surgery in January, she hopes that the implant will help her daughter academically. “The only thing I want for Mila is to be able to use the cochlear implant to support her reading so that she can do more phonics,” she said.
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December 2005
Volume 10, Issue 17